In response to the ongoing concern that closing the inpatient units at St. Lawrence Psychiatric Center will degrade the availability of acute psychiatric care to North Country residents, I add my voice to the worry that the most vulnerable among us and their families will find geographic distance contributing to their daily struggle to function and be well. Mostly, those experiencing psychiatric emergencies are unnoticed by the majority of North Country residents, largely because an efficient and caring treatment system responds and provides effective stabilization and sometimes long-term care, and also because the most vulnerable among us do not identify themselves and thus have no voice. Moreover, degrading the availability of inpatient care degrades these vulnerable individuals and marginalizes their existence.

More specifically, while working as a psychologist on the children and youth inpatient units, I noticed that availability of treatment staff (psychiatrists, psychologists, social workers, nurses, educators, therapy aides, and safety officers) providing direct care to children and families in crisis facilitated the most favorable outcomes, especially for the 4 and 5 year-old children separated the first time from their parents. Similarly, access to staff by parents helped alleviate anxiety and accelerated the stabilization process, and points to the benefit of access to emergency mental health services as close to home as possible.

Relocating inpatient mental health services to a distant center may save money, which is always applaudable, but logistical problems associated with travel in sometimes unpredictable weather complicates the picture for parents, some of whom do not have reliable transportation. As is well known by children and youth treatment staff, a minor child's parents or legal guardians must be present at admission to inpatient care to sign permission to treat forms, identify and sign consents, and provide essential information to the admitting physician about the child's developmental history and health status. Parents or guardians of minor children must also be aware of and sign a treatment plan, usually generated within several days after admission, and may require another visit by the parents or guardians to the psychiatric hospital. Also well-known is the equivalent status of a psychiatric emergency to a medical emergency, in that, a child sent by an emergency department to a psychiatric hospital for inpatient admission must be transported by ambulance, with trained medical staff. Increased geographic distance inevitably increases cost of transportation, a cost that may be prohibitive for most families, a bill that may be rejected by insurance companies and Medicaid, a bill that could be passed on to the psychiatric hospital.

While most of my comments focus on children and youth inpatient services at St. Lawrence Psychiatric Center, I began my career in mental health in the mid-1980s at a small OMH licensed outpatient clinic in a rural upstate New York county. At the time, an effort to reduce the size, scale, and population of psychiatric hospitals in New York State was underway. As a result, many chronic adult patients were "de-institutionalized" and sent to outpatient clinics throughout the state. The money saved from this effort was to be re-invested in expanded outpatient services in the communities to where these fragile people were discharged. However, the promised "re-investment" money never arrived to rural clinics, was apparently re-allocated elsewhere, and the vulnerable people with chronic mental illness became homeless or became inmates at county correctional facilities and state prisons. I encountered many of them a few years later while serving three rural counties as a psychologist on a three person forensic mental health team. I worry that a pattern could develop.

Finally, I want to commend the treatment staff and administration at St. Lawrrence Psychiatric Center for professional acumen and commitment to providing effective psychiatric care for adult and child/adolescent populations presenting with persistent psychiatric disabilities, transient acute psychiatric emergencies, day treatment needs, and outpatient mental health treatment needs. As a retired mental health professional still working part-time in the community, I continually encounter the "product" as well as the "need." The product is the many people receiving essential psychiatric care for persistent mental illness, but who learn to control and manage symptoms and improve function; the product is also those who have been genuinely helped by SLPC inpatient and outpatient staff and who are doing well, working, attending school, and involved in rewarding careers and relationships. These are people who are indistinguishable from everyone else, except they have a history of psychiatric care, no longer needed. I encounter the need regularly, in that, there are many children, families, and adults who live in psychological crisis and could become casualties or precipitate casualties without effective treatment. Their lives are unpredictable and chaotic; their behaviors are dangerous to themselves and others, and they need immediate intervention, expert intervention. Some suffer in silence, behind the mask of psychosis and unable to care for themselves or their children. Without access to treatment, they are lost and represent a human tragedy that we read about in the newspapers or view on the evening news, wondering why someone failed to notice. St. Lawrence Psychiatric Center has the knowledge and skill to alleviate these problems, here in the North Country.